Management of Epididymitis
The management of epididymitis requires targeted antimicrobial therapy based on the patient's age and likely causative organisms, along with supportive measures including bed rest, scrotal elevation, and analgesics until fever and local inflammation subside. 1
Diagnosis
Before initiating treatment, the following diagnostic steps should be performed:
- Evaluate for unilateral testicular pain and tenderness; hydrocele and palpable swelling of the epididymis are usually present
- Distinguish from testicular torsion (surgical emergency) which presents with sudden onset pain, high-riding testicle, and absent cremasteric reflex
- Perform the following tests:
- Gram-stained smear of urethral exudate for diagnosis of urethritis and presumptive diagnosis of gonococcal infection
- Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
- Examination of first-void urine for leukocytes if urethral Gram stain is negative
- Syphilis serology and HIV counseling and testing 1
Treatment Algorithm
For patients ≤35 years (likely sexually transmitted infection):
For patients >35 years, those with enteric organisms, or allergies to cephalosporins/tetracyclines:
- Ofloxacin 300 mg orally twice a day for 10 days
- OR
- Levofloxacin 500 mg orally once daily for 10 days 1
Supportive measures (for all patients):
- Bed rest
- Scrotal elevation
- Analgesics until fever and local inflammation subside 1
Etiological Considerations
The treatment approach varies based on the likely causative organisms:
- In sexually active males 14-35 years: N. gonorrhoeae and C. trachomatis are most common pathogens 3
- In men who practice insertive anal intercourse: Consider enteric organisms 1, 3
- In men >35 years: Usually caused by enteric bacteria (most commonly E. coli) transported by reflux of urine into ejaculatory ducts secondary to bladder outlet obstruction 3, 4, 5
- In HIV-infected patients: Same treatment regimen as HIV-negative patients, but be aware that fungi and mycobacteria are more likely causes in immunosuppressed patients 1
Follow-Up
- Reevaluate if no improvement within 3 days of treatment initiation
- If swelling and tenderness persist after completing antimicrobial therapy, comprehensive evaluation is needed
- Consider differential diagnoses including tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis 1
Management of Sexual Partners
- For epididymitis caused by N. gonorrhoeae or C. trachomatis, refer sex partners for evaluation and treatment
- Partners should be referred if contact occurred within 60 days preceding symptom onset
- Advise patients to avoid sexual intercourse until they and their partners complete therapy and are symptom-free 1
Potential Complications
Untreated acute epididymitis can lead to:
- Infertility
- Chronic scrotal pain
- Abscess formation
- Testicular ischemia 3
Important Caveats
- Always consider testicular torsion in the differential diagnosis, especially with sudden onset of pain, as this is a surgical emergency requiring immediate intervention
- Rising resistance to fluoroquinolones in E. coli isolates may necessitate alternative antimicrobials for treating epididymitis caused by enteric organisms 4
- Clinical resolution may lag behind microbiological cure; local pain and swelling may persist for weeks despite appropriate antimicrobial therapy 6
- Only about 50% of men diagnosed with epididymitis are tested for gonorrhea and chlamydia, highlighting the importance of appropriate diagnostic testing 5
Remember that prompt diagnosis and appropriate treatment are essential to prevent complications such as infertility and chronic scrotal pain.